Healthcare Provider Details

I. General information

NPI: 1689708133
Provider Name (Legal Business Name): RANDYS HOUSE OF MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 FRONT ST
TAYLORSVILLE MS
39168-0818
US

IV. Provider business mailing address

PO BOX 818
TAYLORSVILLE MS
39168-0818
US

V. Phone/Fax

Practice location:
  • Phone: 601-785-6812
  • Fax: 601-785-4993
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number01523
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DIANE WYATT
Title or Position: OWNER
Credential:
Phone: 601-785-6812